MEDICAL HISTORY FORM Today’s Date: ______________ Name: ______________________________________________ Age: ______ Sex: M Height: __________ F Occupation:________________________________ Are you right/left handed or ambidextrous: (Circle one) Right Is your problem the result of an injury? Yes No Left Ambidextrous (Circle one) Date of injury: ___________ Did your injury occur at work? Yes If your injury occurred at work, have you filed a Workers’ Compensation claim yet? Yes Are you working now? Yes No (Circle one) Weight: __________ No No (Circle one) If not, date that you last worked: _________ Visit Information: Chief Complaint: _____________________________________________________________________________________ Date of injury/onset: ____________________ Is it right, left, or both? Right Left Both (Please circle one) Allergies: ________________________________ Type of reaction: _____________________________ No known allergies  ________________________________ Type of reaction: _____________________________ ________________________________ Type of reaction: _____________________________ Medication List: Name Pharmacy Name:______________________________ Pharmacy Phone#: ________________________ Dose Frequency __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ MEDICAL HISTORY Yes No Yes No Yes Anesthetic complications Bleeding disorder Cancer COPD Hepatitis Hypertension Myocardial infarction Reflux Thyroid Osteoarthritis Arrhythmia Blood Disorder Cataracts Diabetes High Cholesterol Kidney disease Pancreatitis Rheumatology Ulcers Fibromyalgia Asthma CAD CHF Heart Disease HIV/AIDS MRSA Varicosities/Phlebitis Stroke Liver Disease Weight Change Sleep apnea Chest pain/Angina Hernia No Other Medical History: ________________________________________________________________________________________________ Page 1 SURGICAL HISTORY Yes No Yes No Yes Ankle Surgery Appendectomy Arthroscopy Knee Arthroscopy Shoulder Bowel Surgery Carpal Tunnel Release Cataract Cholecystectomy Elbow Surgery Foot Surgery Hand Surgery Hernia Repair Hip Surgery Lumpectomy Mastectomy Neck Surgery Total Hip Replacement Revision Total Hip Replacement Hysterectomy Total Knee Replacement Revision Total Knee Replacement Renal Surgery Rotator Cuff Repair Total Shoulder Replacement Tonsillectomy Wrist Surgery No Other Surgical History: _______________________________________________________________________________________________ FAMILY HISTORY Relationship Status Mother Father Brother Sister Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Daughter Son Other Adopted  Family History Unknown  Other Family History: _______________________________________________________________________________________________ TOBACCO HISTORY Do you smoke? Yes No (Circle one) Packs/Day: ______________ Ever Smoked? Yes No (Circle one) Years: ____________ Smokeless Tobacco? Yes No (Circle one) Types? Cigarettes Cigars Pipes (Circle all that apply) Quit Date: ______________ Ready to quit? Yes No Types? Snuff Chew (Circle all that apply) Quit Date: ___________ SOCIAL HISTORY Do you drink alcohol? Yes No (Circle one) Do you use recreational drugs? Types? Types? Beer Wine Liquor (Circle all that apply) Yes No (Circle one) Drinks/week: ______________ Use/week? ______________ IV Marijuana Cocaine Heroin Methadone Xanax Ritalin (Circle all that apply) Page 2 REVIEW OF SYSTEMS Name: __________________________________________ Date: _________________ # ___________________ List your problem and check any symptoms below: __________________________________________________________________________________________________ Review of Systems: Put a check next to any of the following symptoms that you have. General: _____ Fever _____ Night sweats _____ Loss of appetite _____ Unexplained weight change _____ Lumps _____ Frequent headaches Eyes: _____ Blurred vision _____ Double vision _____ See spots Ear, nose, mouth, throat: _____ Ringing in ears _____ Decreased hearing _____ Hoarseness _____ Sore throat (chronic) Abdomen: _____ Pain _____ Nausea/vomiting _____ Constipation _____ Diarrhea _____ Blood in stool _____ Black stools Urinary System: _____ Blood in urine _____ Pain when urinating _____ Increased frequency of urination Musculoskeletal: _____ Pain in joints (circle: hand, wrist, elbow, shoulder, neck, back, hip, knee, ankle, foot) _____ Joint swelling _____ Pain in muscles _____ Arthritis _____ Gout Neurologic: _____ Numbness _____ Passing out _____ Dizziness _____ Weakness of muscles Skin: _____ _____ _____ _____ _____ Rash New mole Change in size or color of mole Non-healing sores Colored lesion under nail(s) Psychiatric: _____ Depression _____ Bipolar _____ Other Endocrine: _____ Change in appetite _____ Cold or heat intolerance (circle) _____ Frequently thirsty Blood/Lymphatic systems: _____ Increase size of lymph nodes Pharmacy Phone # _____________________ _____________________________________ Patient Signature _______________________________ Reviewed By Page 3